Nursing Diagnosis

Definition

In 1990, the North American Nursing Diagnosis Association (NANDA) defined nursing diagnosis as "a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable."

Purpose

The first conference on nursing diagnosis was held in 1973 to identify nursing knowledge and establish a classification system to be used for computerization. At this conference, the National Group for Classification of Nursing Diagnosis was founded; this group was later renamed the North American Nursing Diagnosis Association (NANDA). In 1984, NANDA established a Diagnosis Review Committee (DRC) to develop a process for reviewing and approving proposed changes to the list of nursing diagnoses. The American Nurses Association (ANA) officially sanctioned NANDA as the organization to govern the development of a classification system for nursing diagnosis in 1987. However, the ANA also recognizes the Omaha system and the Home Health Classification system as two additional nursing diagnosis systems currently in use.

The purpose of the NANDA diagnosis list is three fold. First, it provides nurses with a common frame of reference and standardizes language that improves communication among nurses, helps organize research, and is useful in educating new practitioners. Second, nursing diagnoses provide a classification system to describe the scientific foundation of nursing practices—a major criterion necessary for nursing to be recognized as a separate profession, differentiated from medicine and other health care professions. Third, the NANDA diagnosis system has the potential for computer use and may, in the future, provide nomenclature for the reimbursement of nursing activities, not unlike DRGs and ICDs do for medicine.

Precautions

It is important to distinguish nursing diagnoses from medical diagnoses. The two are similar because they are both designed to plan care for a patient. However, nursing diagnoses focus on human response to stimuli, while medical diagnoses focus on the disease process. An example of this difference is the different diagnoses given by a nurse and a doctor to a patient who exhibits difficulty breathing, a productive cough, and crackles throughout lung fields. This patient might be medically diagnosed as having pneumonia. Some nursing diagnoses that might be made for this particular patient, however, include activity intolerance, impaired gas exchange, and fatigue.

Another feature that is unique to nursing diagnoses is the identification of potential problems. The diagnosis of "at risk for aspiration" is an example of a diagnosis that recognizes the potential for a given problem to occur. In order for a risk diagnosis to be made, risk factors must be present and identified upon assessment. In the above example, the absence of the gag reflex, and the presence of facial droop or paralysis may be among the risk factors for impaired swallowing that would lead a nurse to make the diagnosis of "at risk for aspiration." These diagnoses are important because they allow nursing to take a preventive approach to patient care.

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KEY TERMS

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Expected outcome—A measurable individual, family, or community state, behavior, or perception that is measured along a continuum and is responsive to nursing interventions.

Medical diagnosis—A medical determination of disease or syndrome performed by a physician. The focus is on the disease process and the physical, genetic, or environmental cause of that process.

NANDA, North American Nursing Diagnosis Association—Formed in 1973, this group is responsible for developing a classification system of nursing diagnoses.

NIC, Nursing Interventions Classification— Developed by the Iowa Intervention Project, this is a collection of nursing interventions linked to the NANDA diagnoses. The 2000 publication includes approximately 500 interventions.

NOC, Nursing Outcomes Classification— Developed by the Iowa Outcome Project, this is a comprehensive, standardized classification of patient outcomes developed to evaluate the effects of nursing interventions. The outcomes may be linked to the NANDA diagnoses and other diagnoses systems. The 2000 publication includes 260 outcomes.

Nursing assessment—The way in which a nurse gathers and evaluates data about a client (individual, family, or community). The assessment includes a physical examination, interviewing, and observations. Assessment is also the first step in the nursing process.

Nursing diagnostic statement—The formal, written documentation of a nursing diagnosis. It includes the label or diagnosis, the etiology, and the indicators. In the statement, the etiology is preceeded by the phrase "related to." The indicators are the assessment data that led to the diagnosis. They are preceeded by the phrase, "as evidenced by."

Nursing intervention—Any treatment that a nurse performs on a patient in response to a nursing diagnosis to reach a projected outcome.

Risk diagnosis—A nursing diagnosis that recognizes a potential problem not an existing problem. The indicators for risk diagnoses are risk factors that are identified through assessment.

Source : http://www.enotes.com/nursing-encyclopedia/nursing-diagnosis